MRCOG WORKSHOP

Group 1

Case :◦ A 19-year-old G2P0A1 woman at 7 weeks’ gestation by last menstrual period (LMP) complains of vaginal spotting. She denies the passage of tissue per vagina, any trauma, or recent intercourse. Her past medical history is significant for a pelvic infection approximately 3 years ago. She had used an oral contraceptive agent 1 year previously. Her appetite is normal. ◦ On examination, her blood pressure (BP) is 100/60 mm Hg, heart rate (HR) is 90 beats per minute (bpm), and temperature is afebrile. The abdomen is non-tender with normoactive bowel sounds.◦ On pelvic examination, the external genitalia are normal. The cervix is closed and non tender. The uterus is 4 weeks’ size, and no adnexal tenderness is noted. The quantitative beta-human chorionic gonadotropin ((3-hCG) is 2300 mlU/mL . A transvaginal sonogram reveals an empty uterus and no adnexal masses

introduction◦ Definition : Ectopic pregnancy, also known as tubal

pregnancy, is a complication of pregnancy in which the embryo attaches outside the uterus.

◦ Incidence : EP is common and it occurs in 1-2% of pregnancies .

◦ Sites : The vast majority (around 95%) of EPs result from implantation of the fertilized oocyte in the lumen of the fallopian tube. Other sites of implantation include the ovary, abdominal cavity, cervical canal, and interstitial portion of the Fallopian tube.

Approach to vaginal bleeding in early pregnancy

History ◦ The chief complaint is vaginal bleeding

◦ Ask about the amount? Color? vaginal discharge( foul smelling)?  experiencing the symptoms of pregnancy, such as nausea, vomiting and breast tenderness or not? Associated symptoms (e.g., fever, abdominal pain, passage of “tissue,” and shoulder pain) aggravating factor (trauma)?

◦ Past medical history : if there is history of PID ? History of bleeding disorders and clotting abnormalities ? DM? Hypertension? Hyperthyroidism?

◦ Past surgical history : Prior tubal surgery? Pelvic/abdominal surgery (such as appendicectomy, caesarean section, or surgical female sterilization) ?

◦ Drug history : ask about using of medications, specifically anticoagulation therapy , quinine, ergots

◦ Family history : if there is chromosomal abnormalities ?

◦ Social history: smoking ? Alcohol ?

History ◦ Past gynecological history :

◦ Last menstrual period, menstrual regularity?

◦ Use of OCP ? Current IUD use ? Hx of infertility ?

◦ Cervical infection?

◦ uterine anomaly ?

◦ Past obstetric history :

◦ details about previous pregnancy? Previous ectopic pregnancy? Previous abortion ?

Examination • Physical examination

• 1. Vital signs In ruptured ectopic pregnancy: ◦ orthostatic hypotension◦ Tachycardia or hypotension• 2. General examination • inspectionIn general looking : (comfortable, consciousness, alert, dyspnea, cannula,iv line) In ectopic pregnancy — shock or collapse if rupture tube And not comfortable due to the pain 

• Regional examination included (hand, face ,thyroid, breast, abdomen , pelvic

• 3. Abdominal examination• inspection Abdomen:  Inspection of the abdomen for distension, symmetry, striae gravid arum, lina nigra, scars of previous operation, edema, fetal movement if present

In ectopic pregnancy—mild abdominal distention

Palpation: -General palpation— Palpate Abdomen for,tenderness or mass 

In ectopic pregnancy—- abdominal tenderness, peritonism (due to intra-abdominal blood if ectopic ruptured) (Generalized abdominal rigidity and rebound tenderness are present)

◦ Speculum examination:◦ Amount of bleeding◦ Origin of bleeding: uterine, cervical, other (vaginal wall,

perineal, rectal, urinary)◦

Presence of cervical os dilatation, cervical lesions◦ Passage of conception products

Bimanual examination: assessing the cervix :( open or close , length ,consistency , cervical excitation tenderness ) Ep— cervical excitation and tenderness Assessing the uterus: (size , shape,consistency  , position, present of any tenderness , mobility)Ep —- normal Uterine size , Pelvic tendernessAdnexal mass / tendernessAssessing the adnexal : for any masses or tenderness Ep — adnexal tenderness and adnexal mass very rarely

Investigations

THE INVESTIGATIONSBy Israa Saadoon

TRANSVAGINAL UTRASOUND FINDINGS

➤Uterine

➤1) empty uterus

➤2) variable degree of thickening of endometrium

➤3) intrauterine pseudo sac

➤Adnexal

➤1) hyperechogenic tubal ring ( doughnut or Bengal sign )

➤2) mixed adnexal mass

➤3) ectopic sac with with a yolk sac or embryo with/out heart beat

➤4) fluid in the pouch of douglas

➤** the corpus leutum maybe present in the ipsilateral side in 85% of cases

Doughnut sign Thin endometrium

Intrauterine pseudo sac

Fluid in Pouch of Douglas

SITES OF ECTOPIC PREGNANCY

➤ Tubal ( most common )

➤ Heterotopic

➤ Interstitial

➤ Cervical

➤ Ovarian

➤ Abdominal

➤ Caesarean scar

LAPAROSCOPY➤ Patients in pain and those who are hemodynamically unstable should proceed to

laparoscopy. Laparoscopy allows assessment of the pelvic structures, the size and exact location of the ectopic pregnancy, the presence of hemoperitoneum , and the presence of other conditions, such as ovarian cysts and endometriosis, which, when present with an intrauterine pregnancy, can mimic an ectopic pregnancy. Furthermore, laparoscopy provides the option to treat once the diagnosis is established.

➤The routine use of laparoscopy on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies; as more ectopic pregnancies are diagnosed earlier in gestation, the rate of false-negative results with laparoscopy would be expected to rise.

Expectant management means that we expect ectopic pregnancy to

resolve naturally without any intervention. It will be closely monitored by the hospital instead of

having immediate treatment.Identification criteria:

1_tubal ectopic pregnancy only 2_adnexal mass of less than 3.5 cm

3_without heart beat 4_initial BHCG <1000 IU/L 5_Hemoperitoneum <50 ml

Success rate up to 60%

For women with tubal ectopic pregnancy being managed expectantly, repeat HCG levels on day 2,4 and 7 after the original test.If HCG levels drop by 15% or more from the previous value on days 2,4 and 7, then repeat weekly until a negative result (less 20IU/L) is obtained or their urine pregnancy test is negative. if they experience significant increase in abdominal pain,heavy vaginal bleeding,unpleasant smelling vaginal discharge,change in the level of consciousness,Women in whom serum β-hCG levels increases to ≥ 2000 IU/L during follow up or show sustained rise on repeated measurements are also advised to discontinue expectant management and start another treatment.

The benefits of expectant management of ectopic pregnancy?• Expectant management is a safe and effective option for appropriately selected cases.• The aim is to avoid an operation or medications with side effects.• The fallopian tube is not removed.

Medical managment:

The overall success rate of medical treatment in properly selected women is nearly 90% .In a majority of

cases with tubal ectopic pregnancy, a single dose treatment of MTX 50 mg/m2 intramuscularly is

sufficient. Then measure B HCG at day 4 and 7.The level of B HCG should be decreased by about 15%.After initial response,B HCG should measured weekly until zero.A

second dose of MTX might be needed (15–20% of women) and patients should be made aware of this

before the treatment.For other types of ectopic pregnancy, including cervical or interstitial ectopic

pregnancy, a multidose treatment is a better choice.

Candidate for medical treatment:1_B HCG <5000IU/L2_unruptured sac <3.5cm 3_without cardiac activity 4_stable clinical condition

The teratogenic nature of methotrexate means a 12- week washout period is recommended before a further attempt to conceive.

Contraindication to methotrexate in ectopic pregnancy:Absolute:1-Active pulmonary disease2- Alcoholisim,alcoholic liver disease, chronic liver disease.3-Hematological dysfunction 4-peptic ulcer 5-Renal diseaseRelative :1-BHCG >5000 IU/L2-Cardiac activity 3-sac >3.5cm

Befor giving methotrexate you should do CBC ,LFT,RFT

Surgical managment : It is the most appropriate option for cases of

unsuccessful medical or expectant management or in cases where intraperitoneal bleeding is suspected.

In haemodynamically unstable :Anti shock treatment including :

1-wide bore IV lines 2-blood for grouping,cross matching,HB,PT,PTT

3-Catheterization done 4-Laprotomy done and salpingectomy is the definitive

treatment.

The he haemodynamically stable woman who requires surgical management for EP will require the same preoperative measures which can be undertaken in a more considered manner. Candidate for surgical managment:when the adnexal mass is considered large (>35  mm in diameter), fetal heart motion is seen in the adnexal mass, there is ultrasound evidence of intraperitoneal bleeding, there is moderate to severe abdominal pain, or if the woman prefers surgical management .Laparoscopy is the preferred alternative to open surgery (laparotomy) as it is associated with a shorter recovery time, less pain, and a faster return to normal activities.

The surgeon then has the choice of performing a salpingectomy or removing only the pregnancy tissue from the affected tube and leaving the tube in situ (salpingotomy). This will depend on the amount of bleeding, the appearance of the other fallopian tube, and the discussion with the woman prior to surgery regarding her wishes. A salpingotomy is required if the woman wishes to conceive naturally in the future and the contralateral tube appears to be unhealthy, damaged, or absent. This could result from previous infection, surgery, endometriosis, or previous EP. .

It can be difficult to know if all the pregnancy tissue has been removed when performing a salpingotomy, so follow- up serum hCG concentration monitoring is essential until the final resolution. There is an estimated 4– 8% risk of residual trophoblast cells in the treated fallopian tube, which can multiply and cause further bleeding.Surgery for EP is considered a potentially sensitizing event in the United Kingdom in rhesus- negative blood group women without prior sensitization, so 250 IU of anti- D immunoglobulin via intramuscular injection is recommended.

Cervical ectopic pregnancy :In stable patients, medical treatment with

methotrexate is preferable. Most of the data on cervical pregnancy are derived from case series, and

most experts advocate treatment with multidose methotrexate regimen. Due to the high risk of severe

bleeding from cervical pregnancy leading to hysterectomy, we advise against singledose

methotrexate regimen and local injection of methotrexate for the treatment of CEP. We

recommend administering methotrexate 1 mg/kg body weight intramuscularly on days 1, 3, 5, and 7 alternating with leucovorin 0.1 mg/kg body weight

intramuscularly on day 2, 4, 6, and 8.

Surgical management should be used only for patients with severe bleeding or when medical treatment combined with UAE has failed.

Furthermore, methotrexate treatment in most cases will be successful without the need of UAE. UAE as an adjuvant treatment has also been successful in treating CEP in different situations including acute/semi-acute bleeding, before curettage to minimize bleeding, and after failed medical treatment with methotrexate.In women who wish to preserve their fertility and require surgery due to massive bleeding, the surgical treatment consists of curettage preceded by ligation of the descending branch of uterine artery and followed by tamponading with either a Foley catheter inserted into the endocervical canal or a cervical cerclage and vaginal packing.

CS ectopic pregnancy:

Transabdominal or Transvaginal US-Guided Local, Intragestational Sac Injection of MTX/ KCI No

anesthesia is required. Intragestational sac injections had the lower rates of complications (10.8 %). Usually 50–75 mg MTX is the dose used. This treatment was associated with the

lowest complication rate [4

Abdominal ectopic pregnancy :

Due to the risk of infection, peritonitis, and intra-abdominal hemorrhage with maternal

exsanguination, surgical intervention is recommended in cases of abdominal pregnancy.

The more difficult management decisions lie around placental management. There are three

options pertaining to the placenta. The first is to attempt removal; however, this should only be

pursued if the placenta separates easily and there is no collateral blood supply to adjacent vital

organs.

The second option is to leave the placenta in situ and await spontaneous resorption. The last option is to leave the placenta in situ but to administer postoperative methotrexate with the goal of expediting placental involution. With this option, there are some concerns surrounding rapid necrosis that may increase bacterial growth and the risk of associated intra-abdominal infection .Unless the placenta is easily removed after fetal delivery, the general recommendation is to leave the placenta in situ.

Literature Review on

Ectopic PregnancyRidha Azeez

Ectopic Pregnancy: Risk Factors, Clinical Presentation and Management2018

DOI: 10.1007/s13224-017-1075-3

Settings and design: This is a one-year prospective, descriptive study.

Ectopic Pregnancy: Risk Factors, Clinical Presentation and Management2018

Results:

There were 119 ectopic pregnancies during the study period.

The incidence of ectopic pregnancy is 2.81/100 deliveries. Ectopic pregnancy was common in 26-30 years, the minimum age at diagnosis was 18 years and maximum age was 40 years.

Fourteen women had previous one ectopic pregnancy. Four had previous two ectopic pregnancies.

Previous cesarean and treatment for infertility were the commonest risk factors.

The classic triad (pain, amenorrhea, and vaginal bleeding ) was present in only 27.7% of patients. Fourteen patients presented with shock.

Ectopic Pregnancy: Risk Factors, Clinical Presentation and Management2018

Five women were diagnosed even before they missed their periods.

Success rate of medical treatment with methotrexate is 83.33%. Tubal pregnancy was the commonest type, and ampulla was the commonest site.

Right side was affected more than left side.

Thirty-three patients (27.7%) required blood transfusion. Seven developed morbidity.

After 1-year follow-up of 68 women who were desirous of fertility, five women have become pregnant subsequently with intrauterine gestation.

The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery2005

https://doi.org/10.1093/humrep/deh770

A prospective, observational study.

6621 Women were diagnosed with an EP using TVS.

CONCLUSIONS: 90.9% of ectopic pregnancies in this study population can be accurately diagnosed using TVS prior to surgery.

The diagnosis of an ectopic pregnancy should be based on the positive visualization of an adnexal mass using TVS. This should in turn result in a decrease in the number of false positive laparoscopies.

Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis2018

DOI:https://doi.org/10.1016/j.ajog.2019.01.002

Objective: To compare the treatment success and failure rates, as well as side effects and surgery rates, between methotrexate protocols.

Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis2018

Results:

The 2-dose protocol was associated with higher treatment success compared to the single-dose protocol (odds ratio [OR], 1.84; 95% CI, 1.13, 3.00).

The 2-dose protocol was more successful in women with high hCG (OR, 3.23; 95% CI, 1.53, 6.84) and in women with a large adnexal mass (OR, 2.93; 95% CI, 1.23, 6.9).

The odds of surgery for tubal rupture were lower in the 2-dose protocol (OR, 0.65; 95% CI, 0.26, 1.63), but this was not statistically significant.

The length of follow-up was 7.9 days shorter for the 2-dose protocol (95% CI, −12.2, −3.5).

Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis2018

The odds of side effects were higher in the 2-dose protocol (OR, 1.53; 95% CI, 1.01, 2.30).

Compared to the single-dose protocol, the multi-dose protocol was associated with a nonsignificant reduction in treatment failure (OR, 0.56; 95% CI, 0.28, 1.13).

Conclusion: The 2-dose methotrexate protocol is superior to the single-dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success.

Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant managementAug 2020

DOI: https://doi.org/10.1007/s00404-020-05749-2

Results:

The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012).    

Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p <   0.05).